Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding

Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes?

BACKGROUND

In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants.

OBJECTIVE

To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB.

METHODS

Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality.

RESULTS

From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups.

CONCLUSION

Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.

Urgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding?

INTRODUCTION

The main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial.

MATERIAL AND METHODS

Prospective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality.

RESULTS

A total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008).

CONCLUSION

Urgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy).

How Can Patient's Risk Dictate the Timing of Endoscopy in Upper Gastrointestinal Bleeding?

INTRODUCTION

Although upper gastrointestinal bleeding (UGIB) management has improved substantially in the last decades, there is still much controversy regarding the optimal timing for performance of endoscopy. Recent guidelines suggest performing an early endoscopy within 24 h of nonvariceal UGIB (NVUGIB) presentation, although its impact on patients with different bleeding risks remains unclear.

AIM

To evaluate the impact of performing endoscopy within 24 h on NVUGIB outcomes and to compare it in patients with lower-risk vs. higher-risk bleeding.

METHODS

This is a retrospective cohort study including consecutive patients undergoing upper endoscopy for suspected NVUGIB over 4 years. Demographic, clinical, biochemical, endoscopic, and outcome data were collected. Lower-risk bleeding was defined as a Glasgow-Blatchford score (GBS) <12 and higher-risk bleeding was defined as a GBS ≥12.

RESULTS

A total of 298 patients with suspected NVUGIB were included, 55% of whom had higher-risk bleeding. Endoscopy was performed within 24 h in 62.1% of the patients. In lower-risk bleeding patients, performance of endoscopy within 24 h was associated with a higher need for endoscopic treatment (OR = 2.6; 95% CI 1.2-5.7; p = 0.004), a lower 30-day mortality (OR = 0.41; 95% CI 0.27-0.63; p = 0.03), and a lower need for transfusion (OR = 0.58; 95% CI 0.36-0.92; p = 0.02). In higher-risk bleeding patients, there were no statistically significant differences in NVUGIB outcomes in performing endoscopy within 24 h.

CONCLUSION

Endoscopy within 24 h of presentation was associated with a lower need for transfusion, a higher need for endoscopic treatment, and a lower 30-day mortality in lower-risk NVUGIB patients. Thus, performing endoscopy within the first 24 h of presentation can have a positive impact on NVUGIB outcomes even in lower-risk bleeding.

Impact of time to esophagogastroduodenoscopy in patients with nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis

INTRODUCTION

There is conflicting evidence regarding the benefit of urgent esophagogastroduodenoscopy (EGD) for reducing mortality and rebleeding, in the context of nonvariceal upper gastrointestinal bleeding.

AIM

To describe the decrease in the risk for mortality, rebleeding, and red blood cell transfusion, with the performance of urgent EGD, in patients with nonvariceal upper gastrointestinal bleeding.

MATERIALS AND METHODS

We carried out a search for cohort studies or controlled clinical trials, published from December 1966 to May 2020, that compared urgent EGD versus elective EGD in the management of adults with nonvariceal upper gastrointestinal bleeding, utilizing the MEDLINE, Embase, LILACS, and Cochrane Central Register of Controlled Trials databases. Our primary outcome was the hospital mortality comparison. The incidence of rebleeding and the mean number of red blood cell units transfused were also compared. A random effects model was utilized for the meta-analysis.

RESULTS

Twenty-one studies that met the eligibility criteria were included, involving 489,622 patients. We found no differences in the mortality of subjects exposed to urgent EGD versus elective EGD (RR 1.12 [0.72-1.72]). There was a significant increase in the risk for rebleeding (RR 1.30 [1.05-1.60]) in the subjects exposed to urgent EGD, and fewer red blood cell units were transfused in those patients (RR 0.52 [0.05-0.99]).

CONCLUSIONS

Urgent EGD in subjects with nonvariceal upper gastrointestinal bleeding does not appear to have a significant impact on short-term mortality.

The mortality rate among patients with acute upper GI bleeding (with/without EGD) at Aleppo University Hospital: A retrospective study

Background

acute upper gastrointestinal bleeding (UGIB) is a common medical condition that results in substantial morbidity, mortality, and medical care cost. The mortality rate for patients with acute upper gastrointestinal (GI) bleeding is 5-10%, and it has not changed much since 1945, despite the development in medicines, endoscopy, intensive care units (ICU), and surgical management. We conduct this study to observe some of the factors that predict death in these patients.

Materials and methods

The Study was conducted at the Internal Medicine Department, Digestive Division, Aleppo University Hospital, between July 2018 and June 2020. The study included all patients with acute upper GI bleeding who were admitted to the digestive division during the study period, or who were admitted by other departments requesting an upper GI endoscopy.

Results

This study involved 234 patients, 137 males (58.55%), 97 females (41.45%).The patients' ages ranged between 17 and 81 years old, and the mean age value ± standard deviation was 57.15 ± 22.89 years old.The number of deaths reached 22, at a rate of 9.40%, 14 male deaths (10.22%), 8 female deaths (8.25%).

Conclusions

in this study we found a moderate inverse relationship between the hemoglobin value at admission and the incidence of death; the lower the hemoglobin value at admission, the higher the probability of patient's death. Also, there is a very significant direct relationship between the number of blood units transfused and the incidence of death, noting that all patients who died had received blood transfusions. Finally, we found a moderate inverse relationship between the arterial blood pressure value at admission and the incidence of death.

Which scoring system should be used for non-variceal upper gastrointestinal bleeding? Old or new?

BACKGROUND AND AIM

Several scoring systems for predicting outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB) have recently been devised, but not sufficiently validated. We compared the predictive accuracy of several scoring systems and assessed the usefulness of new scoring systems.

METHODS

The medical records of 1048 patients with NVUGIB were reviewed to collect demographic, clinical, laboratory, and endoscopic data. The areas under the receiver operating characteristic curve (AUROCs) were calculated for the ABC, new Japanese scoring system, Progetto Nazionale Emorrhagia Digestiva (PNED), and other scores to compare their predictive accuracy for 30-day mortality, therapeutic intervention, rebleeding, and prolonged hospital stay (≥ 10 days). Outcome predictors were identified by multivariate analysis.

RESULTS

The ABC, new Japanese scoring system, and PNED scores best predicted 30-day mortality (AUROC 0.907), need for therapeutic intervention (AUROC 0.707), and rebleeding (AUROC 0.874), respectively (all P < 0.001). The ABC and PNED scores were similarly better at predicting prolonged hospital stay (ABC AUROC: 0.765; PNED AUROC: 0.790; both P < 0.001). Thirty-day mortality was related to sex, systolic blood pressure (SBP), syncope, estimated glomerular filtration rate (eGFR), albumin, heart failure, disseminated malignancy, chronic obstructive pulmonary disease (COPD), and liver cirrhosis. Sex, age, SBP, hematemesis, blood urea nitrogen, and eGFR independently predicted the need for therapeutic intervention. Sex, SBP, pulse, albumin level, heart failure, disseminated malignancy, and COPD predicted rebleeding.

CONCLUSION

The outcomes of patients with NVUGIB were better predicted by newly developed than by old scoring systems.

Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis

Acute upper gastrointestinal bleeding (UGIB) is the most common indication for urgent endoscopy, but the correct timing of endoscopy in these patients is still debated. Our systematic review with meta-analysis was aimed at investigating the potential clinical benefit of very early endoscopy for UGIB patients. We performed an electronic literature search of PubMed, Scopus, Web of Science and the Cochrane Library up to 23rd May 2020 and considered only randomised controlled trials (RCTs) comparing management of UGIB patients by very early vs early endoscopy. Only five RCTs were considered eligible for quantitative analysis, with a total population of 926 cases (468 in the very early endoscopy arm and 458 in the early). The meta-analysis showed no statistically significant benefit for very early endoscopy compared to early endoscopy in terms of risk of rebleeding, mortality, ICU admission, blood transfusion, surgery and length of hospital stay. However, our results showed a significantly higher need for haemostatic treatment when very early endoscopy was performed (RR 1.23, 95% CI 1.06-1.42, p < 0.01) in comparison to early endoscopy.

Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study

BACKGROUND

Few studies have reported whether a biopsy in emergency gastroscopy (EG) increased the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) combined with suspected malignant gastric ulcer (SMGU). This study aims to conduct a multicenter retrospective cohort study using propensity score matching to verify whether a biopsy in EG increases the risk of rebleeding in patients diagnosed with Forrest I ANVUGIB combined with SMGU.

METHODS

Using the data for propensity-matched patients, logistic regression models were fitted using rebleeding as the dependent variable. Survival time was defined as the length of time the patient experienced from visiting the emergency department to rebleeding. We used the Kaplan-Meier (KM) method to analyze the 30-day survival of the patients with and without a biopsy after matching, and the log-rank test was performed to examine the differences in survival.

RESULTS

With the use of propensity score matching, 308 patients who underwent a biopsy in EG were matched with 308 patients who did not. In the five logistic regression models, there were no significant group differences in the risk of rebleeding in patients with Forrest I ANVUGIB combined with SMGU between the biopsy and no-biopsy groups. The probability of survival was not significantly different between the no-biopsy and biopsy groups.

CONCLUSIONS

In this multicenter, retrospective propensity score matching cohort study, compared with patients without a biopsy, patients with a biopsy during EG had no increased risk of rebleeding, and there was no significant difference in the rate of rebleeding.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Photoacoustic endoscopy: A progress review

Endoscopy has been widely used in biomedical imaging and integrated with various optical and acoustic imaging modalities. Photoacoustic imaging (PAI), one of the fastest growing biomedical imaging modalities, is a noninvasive and nonionizing method that owns rich optical contrast, deep acoustic penetration depth, multiscale and multiparametric imaging capability. Hence, it is preferred to miniaturize the volume of PAI and develop an emerged endoscopic imaging modality referred to as photoacoustic endoscopy (PAE). It has been developed for more than one decade since the first report of PAE. Unfortunately, until now, there is no mature photoacoustic endoscopic technique recognized in clinic due to various technical limitations. To address this concern, recent development of new scanning mechanisms, adoption of novel optical/acoustic devices, utilization of superior computation methods and exploration of multimodality strategies have significantly promoted the progress of PAE toward clinic. In this review, we comprehensively reviewed recent progresses in single- and multimodality PAE with new physics, mechanisms and strategies to achieve practical devices for potential applicable scenarios including esophageal, gastrointestinal, urogenital and intravascular imaging. We ended this review with challenges and prospects for future development of PAE.

Interventional Algorithm in Gastrointestinal Bleeding-An Expert Consensus Multimodal Approach Based on a Multidisciplinary Team

The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.

Validation of a new risk score system for non-variceal upper gastrointestinal bleeding

BACKGROUND

Recently, a new international bleeding score was developed to predict 30-day hospital mortality in patients with upper gastrointestinal bleeding (UGIB). However, the efficacy of this newly developed scoring system has not been extensively investigated. We aimed to validate a new scoring system for predicting 30-day mortality in patients with non-variceal UGIB and determine whether a higher score is associated with re-bleeding, length of hospital stay, and endoscopic failure.

METHODS

A retrospective study was performed on 905 patients with acute non-variceal UGIB who were examined in our hospital between January 2013 and December 2017. Baseline characteristics, endoscopic findings, re-bleeding, admission, and mortality were reviewed. The 30-day mortality rate of the new international bleeding risk score was calculated using the receiver operating characteristic curves and compared to the pre-endoscopy Rockall score, AIMS65, Glasgow Blatchford score, and Progetto Nazionale Emorragia Digestiva score. To verify the variable for the 30-day mortality of the new scoring system, we performed multivariate logistic regression using our data and further analyzed the score items.

RESULTS

The new international bleeding scoring system showed higher receiver operating characteristic (ROC) curve values in predicting mortality (area under ROC curve 0.958; [95% confidence interval (CI)]), compared with such as AIMS65 (AUROC, 0.832; 95%CI, 0.806-0.856; P < 0.001), PNED (AUROC, 0.865; 95%CI, 0.841-0.886; P < 0.001), Pre-RS (AUROC, 0.802; 95%CI, 0.774-0.827; P < 0.001), and GBS (AUROC, 0.765; 95%CI, 0.736-0.793; P < 0.001). Multivariate analysis was performed using our data and showed that the 30-day mortality rate was related to multiple comorbidities, blood urea nitrogen, creatinine, albumin, syncope at first visit, and endoscopic failure within 24 h during the first admission. In addition, in the high-score group, relatively long hospital stay, re-bleeding, and endoscopic failure were observed.

CONCLUSION

This is a preliminary report of a new bleeding score which may predict 30-day mortality better than the other scoring systems. High-risk patients could be screened using this new scoring system to predict 30-day mortality. The use of this scoring system seemed to improve the outcomes of non-variceal UGIB patients in this study, through proper management and intervention.

Outcomes of Upper Gastrointestinal Bleeding Based on Time to Endoscopy: A Retrospective Study

Introduction Non-variceal upper gastrointestinal bleeding (UGIB) is a major burden on the health care system. The timing of endoscopy has been an ongoing debate and data on the association of early endoscopy with a better or worse clinical outcome are conflicting. In our study, we aimed to identify the benefits versus the risks of performing an urgent endoscopy in regards to the number of endoscopic interventions, length of hospital stay, number of packed red blood cells (PRBCs) transfused, and mortality.  Methodology This is a retrospective record-based study. A total of 806 charts were reviewed and 251 patients with the signs and symptoms of UGIB on presentation were included in the study. Patients with variceal bleeding, lower gastrointestinal bleeding, insignificant bleeds with no drop in H/H, GI bleed not being the presenting complaint on admission, and patients on anticoagulation were excluded. Results Out of the patients who underwent an urgent esophagogastroduodenoscopy (EGD), 26.2% needed a second-look EGD 48 hours after the first EGD when compared to 4% and 2% in the early (12-24 hours) and late (>24 hours) endoscopy groups, respectively. In patients who underwent urgent EGD, 23% had active bleeding and it was statistically significant when compared to the other groups. The active bleeding limited the visualization during the endoscopy, which led to a repeat EGD in the urgent EGD group. If an endoscopic intervention was received, patients having EGD >24 hours received a smaller number of interventions. There was no statistical difference in the Blatchford scores between the three groups, indicating that the groups were similar in morbidity. No difference in mortality, hospital length of stay, or number of blood transfusions received, surgical or interventional radiology-guided interventions was found between the three groups. Conclusion Patients who underwent urgent endoscopy had more procedures, with no difference in mortality, number of units of blood transfused, or length of hospitalization when compared to the early or late endoscopy groups.

Current Controversies Concerning Capsule Endoscopy

Video capsule endoscopy became a reality in 2001. This device enabled us to directly view the mucosa of the small intestine for the first time. The main indications for the video capsule remain the detection of small intestinal bleeding and iron deficiency anemia, diagnosis and management of Crohn's disease, and detection of tumors. The device is extraordinarily safe and can be used in the very young to the very old. However, there remain several areas of controversy and difficulty. These are covered in this article and include details of indications and contraindications, whether to prepare patients, whether or not to use simethicone and prokinetics. Detection of location of the capsule remains a major engineering challenge. Reading the videos reliably and quickly remains challenging. However, artificial intelligence and machine learning are already on the horizon to provide assistance. New uses for capsule endoscopy promise more accurate diagnosis and hence improved management of acute gastrointestinal bleeding. The colon capsule may eventually help those who refuse conventional colonoscopy, and robotically controlled capsules may be helpful in screening for serious disease in patients with upper abdominal complaints. The advent of the broadening use of video capsule endoscopy is, though it will be controversial, embraced by some and derided by others; such is the nature of technological development. In the long run, if the use of the video capsule, based on sound evidence-based studies, can be shown to improve the care of our patients and reduce the cost of health care, its use will continue to expand.